Eligibility verification

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Eligibility verification

• Department of Human Services
• December 2008

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Oregon Administrative Rule

• OAR 410-120-1140
• Verification of eligibility
• (1) Providers are responsible to verify a person
  is an Oregon Health Plan (OHP) client with
  appropriate benefits prior to providing services
  in order to ensure reimbursement of services
  rendered. Providers assume full financial
  responsibility in serving a person who the
  provider did not confirm with the Division of
  Medical Assistance Programs (DMAP), is an OHP
  client who, on the date(s) of service, is
  enrolled in a benefit package that covers the
  services rendered.

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Resources

• To verify client medical eligibility, there are 2
  options to choose from, they are
• Automated Voice Response (AVR).
• MMIS Provider Web portal.

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Medical care identification

• Did you notice that the medical care
  identification is not one of the options?
• A new one-time medical care ID card will replace
  the existing monthly ID.
• Each client will have his/her own card.
• The medical care ID card does not guarantee
  coverage.

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Medical care identification

• The medical care
  identification card will
  
  only provide
• Client name
• Client number
• Date the card was issued

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Automated Voice Response (AVR)
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What is AVR?

• The automated voice response (AVR) is a computer
  system that gives
• Client eligibility
• Status of a claim
• Status of a prior authorization request
• Recent payment or suspended claim information
• Benefit limits for eye exams and optical services
• Allows providers to complete automated inquiries
  using a touch-tone telephone.
• AVR is available 24 hours a day, 7 days a week.

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What does AVR provide?

• The AVR can tell you the following information
• A clients Medicaid ID number
• A clients date of birth
• If a client is eligible on a specific date of
  service
• Which benefit plan the client is eligible for
• The clients copayment requirements
• If a service is covered in the clients benefit
  plan
• If the client is enrolled in a managed care plan
• If the client has other insurance coverage
• The date of the clients last vision exam and
  dispensing

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Personal Identification Number

• To access AVR, providers must use the personal
  identification number (PIN) sent by DHS.
• If you have not received your PIN from DHS or you
  need to have your PIN reset, contact
• DMAP Provider Services
• 800-336-6016
• DMAP.providerservices_at_state.or.us
• Monday - Friday, 800 a.m. to 500 p.m.

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(No Transcript)
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Provider Web Portal
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Provider Web portal

• Providers can use the Web portal to
• Verify client eligibility and perform clerk
  maintenance
• Future functions
• Submit, track and view claims
• Submit, track and view prior authorization
  requests
• Perform Health Services Commission (HSC)
  Prioritized List inquiries
• View plan of care information

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Provider Web portal

• The Web portal is free of charge and accessible
  24 hours a day, 7 days a week.
• Access to the Web portal requires
• An Internet connection
• Microsoft Internet Explorer 6 or 7, or Firefox
  2.0
• Provider ID and Personal Identification Number
  (PIN) issued by DHS

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Getting started

• In the address field of your Internet browser,
  type https//www.or-medicaid.gov.
• The session times out after 20 minutes of
  inactivity.
• Any work or changes that have not been submitted
  will be lost.
• If your session expires, you will receive a
  message.

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Web Portal login

• 1. Select Account.
• 2. Select Secure Site.
• Enter your user name and password.
• Select login.

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Home page

• Select Eligibility.

This is the DHS provider that corresponds with
the user name entered on the previous screen.
Provider ID MD Taxonomy Zip
Code -
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Eligibility verification request

• To search for client eligibility use one of three
  combinations
• 1. Client ID and dates of service
• 2. Client SSN, birth date and dates of service
• 3. Client name, birth date and dates of service.
• The Procedure Code field is used to identify
  service limitations for a specific procedure.

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Eligibility verification request

• Enter one of the 3 combinations as indicated on
  the previous page and click search.
• You can view 13 months of historical eligibility
  up to todays date.
• The Provider Web portal will not give future
  eligibility information. All end dates listed in
  your search results are either the date the
  clients coverage ended or the To DOS you
  listed in your request.

XXX
11/30/2008 11/30/2008
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Eligibility search results displays 6 sections
XX X
12/09/2000
5503 [phone]
DOE JANE A

• 1. Client information
• 2. Benefit Plan (formerly benefit package)
• TPL (third party liability)
• Managed Care
• Lockin
• Service Limitations

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Client information section

• The client information section displays basic
  information about the client.

X X X
12/09/2000
5503 [phone]
DOE JANE A
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Benefit plan section

• The benefit plan section gives information about
  the clients benefit plan.
• The following codes indicate DHS benefit plans
  (formerly benefit packages). Disregard all other
  codes they are for internal use only.

Benefit Plan Effective Date
End Date



BMH 04/15/2008
11/30/2008



CRN 04/15/2008
11/30/2008



SMHS 04/15/2008
11/30/2008
BMD OHP with Limited Drug BMH OHP Plus
KIT OHP Standard MED
Qualified Medicare Beneficiary (QMB)
BMM QMB OHP with Limited Drug
CWM Citizen/Alien-Waived
Emergency Medical (CAWEM)
CWX CAWEM Plus
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Third party liability (TPL) section
Carrier Name Policy Number
Policy Holder Coverage Type
Effective Date End
Date Blue Cross
Doe, John
Major Medical 08/01/2000
11/30/2008
Prime Dental
Health
Doe, John Dental
08/01/2000
11/30/2008

• Displays specific information about the clients
  third-party resources (other insurance).

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Managed care section

• The Managed Care section displays information
  about which managed care plan or primary care
  manager the client is enrolled in.
• Plan types are
• FCHP - Fully Capitated Health Plan
• DCO - Dental Care Organization
• MHO - Mental Health Organization
• PCO - Physician Care Organization
• PCM - Primary Care Manager

Provider Name Provider
Phone Plan Type
Effective Date End Date Care Oregon Inc
(503) -
FCHP 11/17/2008
11/30/2008
Mid-Valley
Behavioral Care (503) -
MHO 11/10/2008
11/30/2008
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Lockin section

• If the client is required to use a specific
  pharmacy through the Pharmacy Management Program
  (PMP), that information will be listed in this
  section.

Lockin Plan Effective Date
End Date Provider
Provider Name Provider
Phone Pharmacy
08/01/2000 10/31/2007
NPI My Pharmacy
(503) -
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Service limitation section

• This section shows the next available date for a
  specific service that has limitations according
  to Oregon Administrative Rules.

Service Limitation has been found for Procedure
Code 92002, next possible date of service is
12/01/2008
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Open card example

• 1. This example shows a From/To DOS date
  range.
• 2. Indicates that the client has Medicare Parts
  A, B and D coverage.
• 3. Indicates the client is in the Qualified
  Medicare Beneficiary benefit plan.
• No rows found indicates the client does not
  have any other insurance coverage and is not
  enrolled in a managed care plan during the
  From/To DOS listed in this request.

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Managed care example

• 1. This example shows a From/To DOS date
  range.
• 2. Indicates that the client does not have
  Medicare coverage.
• 3. Indicates the client is in the OHP Plus
  benefit plan.
• Indicates the client is enrolled in Care
  Oregon (medical plan) beginning 11/17/2008, and
  Willamette Dental (dental plan) beginning
  11/10/2008.

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Client not eligible example

• 1. This example shows a specific From/To
  DOS date range.
• Indicates that the subscriber (client) is not
  eligible for the requested From/To DOS date
  range.

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Logging off

• Be sure to logoff when you are done.
• 1. Click Account from the menu bar.
• 2. Click Logoff.

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Logoff notify

• Once logged off, the following message will
  display.

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Contact

• If you need assistance determining client
  eligibility, or other information accessing the
  Provider Web portal, contact
• DMAP Provider Services
• 800-336-6016
• DMAP.providerservices_at_state.or.us
• Monday - Friday, 800 a.m. to 500 p.m.

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Thank you!